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NORTHEASTERN HEALTH SYSTEM
Primary/Alternate Means for Communication
Tag No.: E0032
Based on record review and interview the facility failed to ensure the communication plan contained a specific primary and alternative form of communication as required.
Findings:
Record review showed the facility emergency preparedness plan listed multiple forms of communication but did not delineate which specific ones were the primary or alternate form of emergency communication in the event a disaster occurred.
On 11/09/20 at 1:34 pm the surveyor asked staff E to show them the primary and alternative form of emergency communication in the event a local or facility disaster was to occur. Staff E reviewed the facility emergency preparedness plan and agreed the plan showed several general forms of emergency communication. Staff E stated they will write in specific primary and alternative forms of emergency communication to be in compliance.
Egress Doors
Tag No.: K0222
Based on observation and interview the facility failed to ensure corridor doors in a required means of emergency egress were not equipped with a latch/lock that requires two actions to open from the egress side as required.
Findings:
On 11/10/20 at 2:41 pm a roller latch and thumbturn deadbolt was observed on the CV Director's office door and a barrel latch and pad lock was observed on the volunteer's corridor door which would not allow one action to exit from the egress side.
On 11/10/20 at 2:41 pm staff E was asked why there were multiple corridor doors within the main hospital facility with latch deadbolts which would require two actions to open from the egress side which is not fire code compliant. Staff E stated they will remove the noncompliant deadbolts and roller latches.
Hazardous Areas - Enclosure
Tag No.: K0321
Based on observation and interview the facility failed to maintain a hazardous area free of penetrations as required.
Findings:
On 11/10/20 at 12:01pm the surveyor observed an IT closet which had seven penetrations in the cieling which would allow fire and/or smoke to spread throughout the facility.
On 11/10/20 at 12:03pm the surveyor asked staff E why the IT ceiling was not smoke tight. Staff E stated they were not aware and will get the ceiling repaired as soon as possible.